INFORMED CONSENT FOR BOTULINUM TOXIN TREATMENT

Transcription

1 INFORMED CONSENT FOR BOTULINUM TOXIN TREATMENT PATIENT DATE OF BIRTH ADDRESS PHONE The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is Important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form. THE TREATMENT Botulinum toxin (Botox and similar agents} is a neurotoxin produced by the bacterium Clostridium A. Botulinum toxin can relax the muscles on areas of the face and neck which cause wrinkles associated with facial expressions or facial pain. Treatment with botulin um toxin can cause your facial expression lines or wrinkles to be less noticeable or essentially disappear. Areas most frequently treated are: a) glabellar area of frown lines, located between the eyes; b) crow's feet (lateral areas of the eyes}; c} forehead wrinkles; d} radial lip lines (smokers lines), e) head and neck muscles. Botox is diluted to a very controlled solution and when injected into the muscles with a very thin needle, it is almost painless. Patients may feel a slight burning sensation while the solution is being injected. The procedure takes about minutes and the results can last up to 3 months. With repeated treatments, the results may tend to last longer. RISKSA NO COMPLICATIONS Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy to permit adequate treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to : l. Post treatment discomfort, swelling, redness, and bruising, 2. Double vision, 3. A weakened tear duct, 4. Post treatment bacterial, and/or fungal infection requiring further treatment, s. Allergic reaction, 6. Minor temporary droop of eyelid(s} in approximately 2% of injections, this usually lasts 2-3 weeks, 7. Occasional numbness of the forehead lasting up to 2-3 weeks, 8. Transient headache and 9. Flu-like symptoms may occur. PREGNANCY, ALLERGIE &NEUROLOGI DISEASE I am not aware that I am pregnant and I am not trying to get pregnant, I am not lactating (nursing). I do not have any significant neurologic disease including but not limited to myasthenis gravis, multiple sclerosis, lambert-eaton syndrome, amyotrophic lateral sclerosis (ALS), and parkinson's. I do not have any allergies to the toxin ingredients, or to human albumin. ALTERNATIVE PROCEDURES Alternatives to the procedures and options that I have volunteered for have been fully explained to me.

2 PAYMENT I understand that this is an "elective" procedure and that payment is my responsibility and is expected at the time of treatment. RIGHT TO DISCONTINUE TREATMENT I understand that I have the right to discontinue treatment at any time. BOTULINUM TOXIN (BOTOX ) Pre-Treatment Instructions In an ideal situation it is prudent to follow some simple guidelines before treatment that can make all the difference between a fair result or great result, by reducing some possible side effects associated with the injections. We realize this is not always possible; however, minimizing these risks is always desirable. Patient must be in good health with no active skin infections in the areas to be treated Patient should not be needle phobic Avoid alcoholic beverages at least 24 hours prior to treatment Alcohol may thin the blood, which will increase the risk of bruising. Avoid anti-inflammatory/ blood thinning medications ideally, for a period of two (2) weeks before treatment. Medications and supplements such as Aspirin, Vitamin E, Gingo Biloba, St. John's Wort, Ibuprofen, Motrin, Advil, Aleve, Vioxx, and other NSAIDS are all blood thinning and can increase the risk of bruising/swelling after injections. Schedule Botox appointment at least 2 weeks prior to a special event which may be occurring, i.e., wedding, vacation, etc. etc. It is not desirable to have a very special event occurring and be bruised from an injection, which could have been avoided. BOTULINUM TOXIN (BOTOX ) Post-Treatment Instructions The guidelines to follow post treatment have been followed for years, and are still employed today to prevent the possible side effect of ptosis (drooping of the eyelids). These measures should minimize the possibility of ptosis. No straining, heavy lifting, vigorous exercise for 3-4 hours following treatment. It is now known that it takes the toxin approximately 2 hours to bind itself to the nerve to start its work, and because we do not want to increase circulation to that area to wash away the Botox from where it was injected. Avoid manipulation of area for 3-4 hours following treatment. (For the same reasons listed above.) This includes not doing a facial, peel, or micro-dermabrasion after treatment with Botox. A facial, peel, or micro-dermabrasion can be done in same appointment only if they are done before the Botox. Facial exercises in the injected areas is recommended for 1-hour following treatment. This is to stimulate the binding of the toxin only to the localized area. It can take 2-10 days to take full effect. It is recommended that the patient contact the office no later than 2 weeks after treatment if desired effect was not achieved and no sooner to give the toxin time to work. Makeup may be applied before leaving the office.

3 INFORMED CONSENT FOR DERMAL FILLER TREATMENT PATIENT DATE OF BIRTH ADDRESS PHONE The purpose of t his informed consent form is to provide written information regarding the risks, benefits and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your doctor/healthcare provider. It is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your doctor/healthcare professional prior to signing the consent form. THE TREATMENT Treatment with dermal fillers (such as Juvederm, Restylane, Radiesse and others) can smooth out facial folds and wrinkles, add volume to the lips, and contour facial features that have lost their volume and fullness due to aging, sun exposure, illness, etc. Facial rejuvenation can be carried out with minimal complications. These dermal fillers are injected under t he skin with a very fine needle. This produces natural appearing volume under wrinkles and folds which are lifted up and smoothed out. The results can often be seen immediately. RISKS AND COMPLICATIONS Before undergoing this procedure, understanding the risks is essential. No procedure is completely risk-free. The following risks may occur, but t here may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy to permit adequate treatment. It has been explained to me that there are certain inherent and potential risks and side effects in any invasive procedure and in this specific instance such risks include but are not limited to: 1) Post treatment discomfort, swelling, redness, bruising, and discoloration; 2) Post treatment infect ion associated wit h any transcutaneous injection; 3) Allergic reaction; 4) Reactivation of herpes (cold sores); 5) Lumpiness, visible yellow or white patch.es; 6) Granuloma format ion; 7) Localized necrosis and/or sloughing, with scab and/or without scab if blood vessel occlusion occurs. PREGNANCY AND ALLERGIES I am not aware t hat I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I do not have or have not had any major illnesses which would prohibit me from receiving derma l fillers. I certify that I do not have multiple allergies or high sensitivity to medications, including but not limited to lidocaine. ALTERNATIVE PROCEDURES Alternatives to the procedures and options that I have volunteered for have been fully explained to me. PAYMENT I understand that this is an "elective" procedure and that payment is my responsibility and is expected at the time of treatment. RIGHT TO DISCONTINUE TREATMENT I understand that I have the right to discontinue treatment at any time. TRAINING COURSE I understand that I have volunteered to be a model patient in a training course and the doctor/healthcare professional who will be treating me has had limit ed experience with the method of treatment.

4 I hereby indemnify the American Academy of Facial Esthetics LLC from any liability relating to the procedures that I have volunteered for. I also understand that any treatment performed is between me and the doctor/health care provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician. I hereby indemnify the facility/meeting room/hotel where this treatment is being performed from any liability relating to the procedures that I have volunteered for. PUBLICITY MATERIALS I authorize the taking of clinical photographs and videos and their use for scientific and marketing purposes both in publications and presentations. During courses given by Common Sense Dentistry and/or The American Academy of Facial Esthetics (AAFE), I understand that photographs and video may be taken of me for educational and marketing purposes. I hold the AAFE harmless for any liability resulting from this production. I waive my rights to any royalties, fees and to inspect the finished production as well as advertising materials in conjunction with these photographs. RESULTS Dermal fillers have been shown to be safe and effective when compared to collagen skin implants and related products to fill in wrinkles, lines and folds in the skin on the face. Its effect can last up to 6 months. Most patients are pleased with the results of dermal fillers use. However, like any esthetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that wrinkles and folds will disappear completely, or that you will not require additional treatment to achieve the results you seek. The dermal filler procedure is temporary and additional treatments will be required periodically, generally within 4-6 months, involving additional injections for the effect to continue. I am aware that follow-up treatments will be needed to maintain the full effects. I am aware the duration of treatment is dependent on many factors including but not limited to: age, sex, tissue conditions, my general health and life style conditions, and sun exposure. The correction, depending on these factors, may last up to 6 months and in some cases shorter and some cases longer. I have been instructed in and understand the post-treatment instructions. I understand this is an elective procedure and I hereby voluntarily consent to treatment with dermal fillers for facial rejuvenation, lip enhancement, establish proper lip and smile lines, and replacing facial volume. The procedure has been fully explained to me. I also understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-operative questions or concerns to the treating clinician. I have read the above and understand it. My questions have been answered satisfactorily. I accept the risks and complications of the procedure and I understand that no guarantees are implied as to the outcome of the procedure. I also certify that if I have any changes in my medical history I will notify the doctor/healthcare professional who treated me immediately. I also state that I read and write in English. Patient Name (Print) Patient Signature Date Health History Completed? Yes No Date: Doctor Initial: Dental/ Head and Neck Examination Completed? Yes No Date: Doctor Initial: I am the treating doctor/healthcare professional. I discussed the above risks, benefits, and alternatives with the patient. The patient had an opportunity to have all questions answered and was offered a copy of this informed consent. The patient has been told to contact my office should they have any questions or concerns after this treatment procedure. Doctor Name (Print) Doctor Signature Date

5 PRE-TREATMENT INSTRUCTIONS Dermal filler treatment A few simple guidelines before your treatment can make a difference between a good result and a fantastic one. Patient should be in good overall health. A full medical and dental history must be performed on all patients for optimal results. If you develop a cold sore, blemish, or rash, etc. prior to your appointment you must reschedule. If you have a special event or vacation coming up schedule your treatment at least 2 weeks in advance. Let us know if you are prone to cold sores - a pre-operative medication may help prevent cold sores after treatment. AVOID: Alcohol, caffelne, motrin, gingko biloba, garlic, flax oil, cod liver oil, vitamin A, vitamin E, fatty acids, niacin supplements, high-sodium foods, high sugar foods, refined carbohydrates, spicy foods, or cigarettes 24 hours before your treatment. This is to reduce the incidence of bruising after these procedures. Discontinue Retin-A two (2) days before and two (2) days after treatment. POST TREATMENY INSTRUCTIONS Dermal Filler Treatment DO NOT: touch, press, rub or manipulate the implanted areas for the rest of the day after treatment. Avoid kissing, puckering and sucking movements for the rest of the: day as these motor movements can undesirably displace the implanted dermal filler material. Irritation, sores, and post-operative complications including scarring are possible if you manipulate the dermal filler implants. AVOID: Alcohol, caffeine, motrin, gingko biloba, garlic, flax oil, cod liver oil, vitamin A, vitamin E, fatty acids, niacin supplements, high-sodium foods, high sugar foods, refined carbohydrates, spicy food s, or cigarettes 24 hours before your treatment. This is to reduce the incidence of bruising after these procedures. AVOID: Vigorous exercise and sun and heat exposure for 3 days after treatment. DISCONTINUE: Retin - A 2 days after treatment. It is best to wear no makeup or lipstick until the next day. Earlier use can cause pustules. One side may heal faster than the other side. You can expect some bruising and swelling around the areas that were injected. Apply ice for the first hour after treatment for ten minutes on and ten minutes off. You must wait 2 weeks before any enhancements. ***Please report any redness, blisters, or itching immediately if it occurs after treatment. *** I certify that I have been counseled in post-treatment instructions and have been given written instructions as well. Patient Signature Date